September 24, 2017

This
past week was Rosh Hashanah, the Jewish New Year. I discussed the origins and
evolution of the holiday at my synagogue, observing that the original name of
the holiday, as indicated in the Torah, the Jewish bible, is “The Day of
Shouting.” And what was it that people were supposed to shout about?
Originally, they were supposed to shout out their praise of God. Some of the
admirable qualities that have been attributed to God are “caring for widows and
orphans,” which is biblical shorthand for “caring for the vulnerable,” and “welcoming
the stranger, for you were strangers in the land of Egypt,” which is synonymous
with accepting outsiders, newcomers into the community. But already early on in
Jewish history, and particularly over the last several hundred years, the
tradition is that these “attributes of God” are seen as aspirational—as qualities
that people should strive to emulate in their own lives. So, translating into
contemporary language, on Rosh Hashanah, we are supposed to strive to care for
the poor and the sick and to open our doors to refugees.

But there’s more. Over the centuries, not only have these qualities attributed to God become qualities that people should strive to adopt themselves, but it has also become our responsibility to act. The
shouting that we are supposed to do on Rosh Hashanah is not so much singing God’s
praises as it is calling out to our fellow man to act. And the actions in
question, not surprisingly, include caring for the poor and the sick and embracing
refugees.

The health care bill that is expected
to come to the Senate floor this week is the very epitome of how to avoid
caring for the poor and the sick. If you cannot afford medications, hospital
care, or insurance premiums—that’s your fault. Next time, work harder, go to
better schools or, better yet, choose parents who are themselves smart,
educated, and affluent so they can assure that you, too, will be smart,
educated, affluent—and able to afford to pay whatever it costs to get good
care. In fact, if you have cancer or diabetes or some other chronic, serious condition,
that’s your fault, too, so why should someone else have to subsidize your
treatment? This bill, which pretends to include benefits comparable to those
currently available under the Affordable Care Act, is not a means of providing
health insurance to all those left out by the three other programs for
obtaining coverage: Medicaid, Medicare, and employer-supported insurance.
Rather, it is a strategy to gut Medicaid, one of the three pillars of the
current system. The ACA was designed to take a three-legged stool and enhance
its stability by adding a fourth leg; the latest travesty proposed by Senate
Republicans would instead amputate one of the three legs. So, here’s my shout
out to my fellow Americans: say “no” to the Senate proposal. Shout out to your
senators—especially if you’re from one of those states such as Maine and Alaska
whose senators have previously expressed concern about the poor and the sick in
their states, or if you’re from one of the states that stands to lose the most
from the new bill, such as Florida and Nevada. Shout to those people you know
who live in those states that they should shout out to their senators. Make
this Rosh Hashanah truly the “Day of Shouting.”

September 17, 2017

When a record heat wave
swept across Europe in the summer of 2003, elderly Parisians were particularly
hard hit. “French heat toll almost 15,000,” screamed oneBBC headline in
September. The cause of death: dehydration and hyperthermia. The diagnosis of
the problem: not enough air conditioning, made worse by too many physicians on
vacation in August. Across Europe, over 70,000 people died of heat-related
causes. We thought we were immune: our nursing homes are air conditioned and we
have plenty of nurses, doctors, and regulations. But now we have the disturbing
reports of 8 deaths among nursing home residents of a facility in Florida in
the aftermath of Hurricane Irma. The nursing home lost power and its back-up
generator was useless when a critical component, the transformer, failed.
Despite access to an acute care hospital across the street, no one thought to
transfer the frail, elderly long term care residents until they were already
suffering from severe dehydration and/or hyperthermia. What can we learn from
this very sad story?

First, we should drill down
and look at the specific facility where the problem occurred. All of the west
coast of Florida was affected by the hurricane, after all, but only one nursing
home lost patients. The Rehabilitation Center of Hollywood Hills is a Medicare
and Medicaid licensed 152 bed facility. It is a for-profit nursing home. And if we consult Nursing Home Compare, the site operated by the Centers for Medicare and
Medicaid Services to allow consumers to compare the quality of different
nursing homes, we find that the home currently has an overall rating of two
stars, or below average. Even more revealing is the further breakdown: in the
area of health inspections, it received only one star, or much below average,
though in quality it got three stars (average) and in terms of the staff:
patient ratio it actually got four stars (above average). So what exactly does
this mean?

The problem at Hollywood
Hills was not a failure to follow the rules—the facility had a back up
generator and supplies for seven days (though their ice collection was
presumably not terribly useful if they had no refrigeration). The problem was
judgment. Nobody in charge determined that conditions were too dangerous and
residents needed to be evacuated. They only figured that out after people began
dying, although it takes a couple of days for a lethal degree of dehydration to
set in. What our current evaluation system for nursing home lacks is the
capacity to measure the ability to respond to novel challenges, to be creative.
Perhaps we need to set objective standards, not merely relative standards. If
we set the bar high enough, then the lowest performing facilities would still
be adequate. That said, it’s striking that the overall rating of the facility
was poor. Nursing Home Compare is on to something—we need to have a better way
of insuring that the poorer facilities improve.

The
other take home lesson from the tragedy is that Hollywood Hills was the canary
in the coal mine. Yes, only one nursing home in Florida seems to have behaved
with such monumental lack of understanding of what happens to frail old people
in sustained 100 degree heat. But the truth is that we will see more hundred
degree weather—and more Hollywood Hills behavior—in the future. A recent government report—issued before President Trump and EPA Director Pruitt banned references to “climate change” from official documents, “The Impact
of Climate Change on Human Health in the United States: a Scientific
Assessment,” makes clear that there will be profound, widespread consequences
of rising temperatures. The vulnerable elderly will be among the hardest hit,
but they are merely harbingers of what is to come unless we take major steps now.

September 06, 2017

Kaiser Health News ran an article this week about
“the secret happiness as you age.” It features the story of a 76 year old man
who, despite severe heart disease, diabetes, glaucoma, and osteoarthritis,
describes himself as a “happy guy.” He can’t see well, he can’t drive, and he
has to rest after walking short distances—really short, like 10 yards. So how
does he manage to be happy?

His secret is that he focuses on those things in
life that do bring him joy—listening to music and audiobooks, and writing. He
also derives pleasure from helping others in small ways. The article concludes
with a quote from a geriatrician who says that “the real key to happiness at
every age and stage—particularly old age—is not material things, but gratitude
for life’s simple blessings, like laughter among friends or watching a sunset
with a loved one.”

The message that frailty doesn’t have to spell
misery is a refreshing one. Readers of this blog know that I spend a great deal
of time discussing frailty: defining it, advocating screening for it, and
promoting an “intermediate” approach to care for people who have it. I lament
the disproportionate time and energy spent on addressing robust old age and
dying, two important states but not where most older people spend most of their
time. The Kaiser Health article is an important reminder that we don’t need to
hide frail people from view as though they carry an unbearable, unmentionable
stigma. But what is missing from the piece is the recognition that while
individuals who are frail can take steps to make their lives rewarding, the
larger society has an important supportive role to play.

Creating and
disseminating the technological aids that can make life enjoyable are crucial:
without his audiobooks and his virtual assistant (in the example given,
Amazon’s Alexa), achieving satisfaction might have been impossible. We need to make age-friendly environments, like those promoted by the World Health Organization’s “Age-Friendly Cities and Communities Program.” This means
building walkable communities, providing appropriate transportation, and
linking service providers to individuals. It means developing accessible
housing and means for civic participation, along with access to medical care.
It means joining the AARP Network of Age-Friendly Communities or local
organizations, such as the Massachusetts Healthy Aging Collaborative. Only then
will happiness among frail elders be the norm rather than the exception.